Participant Service Referral Form

Step 1 of 5

Step 1

Participant Name*

First

Last

Date of Birth*

Participant Contact No.*

Participant Email

Participant NDIS Number*

Gender

Address*

Participant's Representative Name

First

Last

Representative's Phone No.

Relationship with Participant

Representative's Email

Support Coordinator

Step 2 of 5

Step 2

Support Coordinator Phone

Organisation

Support Coordinator's Email

Emergency Contact

Emergency Contact Phone

Relationship with Participant

Emergency Contact Email

Language*

English Other Languages

Commnication

Interpreter Required Auslan Assistive Technology Binary TTL

Aboriginal Aboriginal and Torres Strait Islander Torres Strait Islander LGBTIQA+ CALD

NDIS Plan Manager*

NDIA Managed Plan Managed Self Managed

Managed by

First

Last

Step 3 of 5

Step 3

Phone

Accounts Email

What Support Services are you looking for? (Select all applicable).*

Assistance with Daily Personal Activities Assistance with Travel/Transport Arrangements Supported Independent Living Domestic Household Tasks (Cleaning / Gardening etc). Support Coordination Participation in Community, Social and Civic activities Delevopment of Daily Living and Life Skills Disability / Aged Care Support Worker

Primary Disability*

Allergies/Alerts

Secondary Health / Medical Conditions

Support Service Start Date*

Service Provider*

Anticipated Duration of Support Services Required:

Details of support services required:*

You may write about
(1). Primary disability and its impact on current functional status (2). Current health status including any secondary medical conditions impacting participant's functionality, (3). Summary of the Participant’s strengths, goals, objectives and any previous experience, (4) Type of services required with any specific requirements. You may also attach a copy of your NDIS plan below to provide further information and insight into participant's goals and objective (if applicable).

Does the Participant live alone?*

Yes No

Step 4 of 5

Step 4

Is the participant at risk of choking, seizures or anaphylaxis? *

Yes No

Is assist with medication administration required? *

Yes No

Does participant suffer from irritants, phobias or any other specific condition? *

Yes No

Is participant home easy to locate?*

Yes No

Are any gates or doorways difficult to use or access?*

Yes No

At night, is the house entrance hard to find?*

Yes No

Is onsite/street parking available for support worker’s car?*

Yes No

Is there a risk that participant may abscond?*

Yes No

Do you give consent for the support worker to proactively support you in attending medical, and allied health services?*

Yes No

Any pets or animals at home?*

Yes No

Is the participant supported by only one support worker?*

Yes No

Is the home wheelchair accessible?*

Yes No

Step 5 of 5

Step 5

Are there any slip, trip or falling hazards outside or inside the home?*

Yes No

Will the support worker be required to use any electric appliances?*

Yes No

Do you give consent to share this form with your support network, other providers, and relevant government agencies? *

Yes No

Are there any places, situations or specific irritants that should be avoided?

Are there any specific risks associated with transport?

In case of any emergency in the home, please describe the emergency procedure for the support worker to follow. Please consider any special procedures, nearest exits and emergency meeting points?

Is there anything else you would like to share about the participant or home?

Supporting Documents / Current NDIS Plan

Max 10 MB. Accepted: PDF, images, Word documents.

How did you hear about Us? (Select all applicable).*

NDIS Website Clickability Referred Ask Izzy Facebook / Instagram / X Word of Mouth Other Google search

Participant / Representative Signature*

Date*

Your responses are submitted securely and stored in Care Zone's confidential records.